PCofE
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DISTANCE LEARNING DIPLOMA APPLICATION FORM

Personal Details
Title
Surname/Family Name   First Name(s)  
Date of Birth   Gender
 
Home Address
Line 1   Telephone / Mobile  
Town/City   Email  
County/State  
Post/Zip Code  
Country  
 
Correspondence Address (if different)
Line 1
Town/City
County/State
Post/Zip Code
Country
 
Preferred Start Date
Month and year in which you wish to start the courses leading to a Diploma (please note that you can start your course at anytime during the year.)
Month Year
Chosen Diploma
 
Career History / Voluntary Work / Relevant Experience
Job 1
Date from (mm yyyy) to (mm yyyy)
Employer's name
Address
Post Held
Full Time?
Main functions
Reason for leaving
Job 2
Date from (mm yyyy) to (mm yyyy)
Employer's name
Address
Post Held
Full Time?
Main functions
Reason for leaving
 
Academic History / Professional History
Please give details of the last two universities/colleges you attended (most recent first).
If you have not attended a college or university before, please tick this box *
* this will NOT affect your application
University / College 1
Date from (mm yyyy) to (mm yyyy)
Name of Institution
Qualification(s) gained
University / College 2
Date from (mm yyyy) to (mm yyyy)
Name of Institution
Qualification(s) gained
* In order for us to process your application, you must submit a copy of the certficate for any qualifications you have gained.
 
References
Please provide two written academic references from people (not a relative) who have direct knowledge of your work/academic ability.
Reference 1
Name Telephone
Address Email
Reference 2
Name Telephone
Address Email
By ticking this box, I confirm that, to the best of my knowledge, the information given on this form is correct and complete.